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Endo Docs Gaming the System, Study Says

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  • In Coding
  • December 30, 2011
  • Comments Off on Endo Docs Gaming the System, Study Says

A study presented at Digestive Disease Week in Chicago last year suggests that physicians may be deliberately performing endoscopies on different days to avoid bundling—and the attendant reduction of payment—by Medicare payers, reports Internal Medicine News.
Researchers identified 12,905 Medicare beneficiaries who underwent both a colonoscopy and diagnostic upper endoscopy procedure within 180 days of each other. Nearly two-thirds of all procedures were bundled; the remaining procedures (approximately 37 percent) were separated from each other by a median of just 26 days, and approximately 30 percent of procedures not performed on the same day were separated by four or fewer days.
“The lack of bundling was unlikely to be explained by clinical necessity,” commented lead investigator Dr. Hashem B. El-Serag. Rather, El-Serag believes physicians making clinical choices may have been influenced by purely financial concerns.
Providing related endoscopic services on the same day is more convenient, efficient, and cost-effective, but there is a financial disincentive for physicians to embrace this approach. Medicare pays less when two endoscopic procedures are reported for the same patient on the same day. For example, reimbursement for a diagnostic upper endoscopy is approximately $75 when bundled; the payment nearly doubles ($150) if the procedure is reported independently.
The study stopped short of making recommendations to prevent such unbundling of endoscopic services, but lead researcher El-Serag did caution, “The financial implications to the health care system and the increased adverse events in patients are likely to be large.”

Certified Internal Medicine Coder CIMC

No Responses to “Endo Docs Gaming the System, Study Says”

  1. Ben Strickland, CPC says:

    I wonder if Dr. El Serag had clinical and statistical data to support his conetention that proc edures performed on separate days were “unlikely to be explained by clinical neccessity”. If so, then it should have been included in this article. As someone who bills for these procedures on a regular basis, I can state that the clincial circumstances vary on a wide basis. If anything, I think the definition of medical necessity should reside with the physician who is responsible for the care of the patient. If they performed the procedures together too often, they’d be accused of performing unneccessary procedures. Seems to me you can’t win for losing.

  2. Leslee Allen, CPC says:

    Which codes are being referred to…
    I’ve checked for CCI edits and am not able to find any regarding 43239 & 45378

  3. Jenifer, RCC, CPC says:

    Leslee, I think that the article is not referring to the CCI edits, but rather the multiple endoscopy rule that states that additional endoscopic prcocedures in the same family are subject to a multiple payment reduction rule. A good explanation with CMS references can be found here:

  4. Alicia says:

    As a parent of a child that had to go through those procedures Upper Endoscopy and Lower Endoscopy for chronic abdominal pain and nausea with vomiting, I could not imaging having to wait for separate days for those procedures, meaning the patient would have to endure two preps.

  5. Rachel Boggs CMA, CGSC says:

    I find this very interesting. My question is, where these all outpatient (non emergent) cases or were inpatient (emergent) cases included as well. I think running the same study on those two groups may shine more light on this. When billing for my surgeons, I am more likely to see this issue on inpaitients due to emergency circumstances that may not warrant an upper endoscopy but only a colonoscopy or vise versa, and once the patient is able to give more information or after furthur testing, the other scope is deemed necessary.
    On an out patient basis we know we have to accept the multi procedure discount, and the alternative of scheduling the patient on two different days for outpatient endoscopies simply because of reimbursement seems almost fraudulent not to mention completely inconsiderate of a patients time and money.

  6. N. Flowers, CPC says:

    I really want to believe that 75 bucks would not be enough to prompt all but a tiny fraction of physicians to advise separate procedures and preps that could be done together for obvious reasons like patient safety, etc. However, 30% of cases showed a four or less day gap between procedures. That’s a scary statistic but without further information on the study data (inpatient vs. outpatient, etc.) it would be cynical to assume any “gaming” going on. However, after 35 years in the billing and coding/auditing field, I tend to be more cynical when it comes to healthcare decisions being made for the right reasons. I can tell you from personal experience that both my parents were advised to undergo upper and lower endoscopies on separate days (different physicians) although there were no clinical indications that would preclude both procedures being performed during the same session. When I asked about this, I was told it was their “policy” to schedule separately and could not provide any other rationale. They ended up with two procedures on the same day as a result of my query. If it walks and quacks like a duck…

  7. Ron McLaughlin says:

    Here is a specific component of the medical necessity issue that many doctors, not just gastroenterologists, may want to pay attention to. The issue of bundling colonoscopies and other endoscopy procedures is an example of how the Centers for Medicare and Medicaid Services may be looking at a medical necessity issue demographically, where doctors argue that these issues should be looked at on a patient by patient basis. Both approaches may have their merits, but it’s not hard to see how this kind of thing gets tricky and causes more problems for the interaction between government payers and medical providers. Where study leaders referred to the “financial implications to the healthcare system,” further complexity in medical billing is certainly a component of this reference. Oversight like this makes it all the more necessary for doctors to prioritize good record-keeping and approach building strategically in the future. Ron McLaughlin, CEO,

  8. C Lewis CPC says:

    Really… are there any physicians that do not try to maximize their payment levels utilizing insurance rules within reasonable parameters? I’ve had these tests and had physicians tell me they won’t get paid appropriately if they do the procedures in the same session (endoscopy and colonoscopy). As a patient, I disagree because who wants to go through this process twice, but as a business person, I can hardly blame physicians who are struggling to provide more services for less reimbursement and keep up with rising costs of supplies, payroll taxes, rent, etc. Fix the system before physicians and good healthcare become scarce!